Couples HIV Testing and Counselling -- A Novel Approach to Testing

An estimated 25% of people living with HIV in Canada do not know they have HIV. Effective new ways to increase the uptake and frequency of testing are needed.

Recently, a new approach to testing, called couples HIV testing and counselling (couples testing), has been introduced in the U.S. for men who have sex with men (MSM). This article explores what couples HIV testing and counselling is, its advantages and disadvantages, and describes the approach being used in the U.S.

Why Are We Talking About Testing and Counselling?

In Canada an estimated 25% of people living with HIV remained undiagnosed as of 2011.1 Reducing the number of people who are unaware of their HIV status requires effective new ways to increase the uptake and frequency of HIV testing. Testing not only increases awareness of HIV status, it is also an important gateway to prevention, care and treatment services.

A Novel Approach to Testing and Counselling -- Couples HIV Testing and Counselling

Couples HIV testing and counselling is the counselling and testing of two (or more) people together who are in, or about to start, a sexual relationship. In couples testing, partners receive pre-test counselling, are tested for HIV, learn the test results and receive post-test counselling together and are linked to care (if one or both test positive).

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In addition to the diagnostic, prevention, care and treatment benefits of individual HIV testing and counselling, there are many other benefits of a couples approach to testing:2-4

Provides a venue for mutual disclosure of HIV status in an environment where support can be provided by a counsellor or health worker.

Risk-reduction messages can be tailored depending on the outcome of the test results of both partners.

Decisions about prevention, accessing treatment, care and support, and family planning options can be made together.

Moreover, through couples testing, the counsellor can help create a safe environment in which the couple can discuss potentially difficult issues, such as sexual agreements. Sexual agreements are mutually agreed upon conditions or limitations about sexual behaviours within and outside of the relationship. Couples HIV testing and counselling provides a forum for open discussion about sexual agreements, with the help of a counsellor. This helps both partners fully understand the agreement which may better protect them from HIV.

There may be many different approaches to sexual agreements but agreeing to what is acceptable will help reduce the couples' risk for HIV. Couples may agree that if one of them breaks the agreement, disclosure should occur so that informed prevention choices can be made until they can test for HIV and/or other sexually transmitted infections.

A few potential concerns exist with couples testing and counselling. There is concern that people could be coerced into testing. In situations where there is an unequal power dynamic within the couple, one partner may be coerced into testing against his or her will. This should be taken into consideration when designing couples testing and counselling approaches. A questionnaire could be used to screen each individual for partner violence. The use of individual consent forms for testing may also identify situations where one partner is being forced to test.

Another concern is that there may be blame within established or longer-term relationships if one or both people test HIV positive. In order to overcome this issue, counsellors should focus their discussions on present and future HIV risk behaviours not past behaviours.

Adaptation for Men Who Have Sex With Men in the United States

Couples HIV testing and counselling was first used in Rwanda with heterosexual couples in the late 1980s but it has expanded into many African countries over the past 20 years. Research suggests it is an effective approach to testing and has strong HIV prevention benefits.5 In 2007, the U.S. Centers for Disease Control and Prevention (CDC) deemed this program a high-impact HIV prevention approach.

Based on the success in Africa, couples testing and counselling was adapted for MSM in the U.S. This population was chosen for several reasons. The U.S. has a high burden of HIV among MSM -- an estimated 63% of new HIV infections were in MSM in 2010.6

Furthermore, many men in long-term relationships are unaware of their partner's status7,8 but still feel they are at low risk for HIV.9 This makes them less likely to test for HIV. This is problematic since between one-third to two-thirds of all new HIV infections in MSM are acquired from the main partner within a relationship.10,11

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